Hemodynamics Case 6

You are looking after a 50 year old woman on the ICU who had an exploratory laparotomy 18 hours ago and was found to have fecal peritonitis. She was admitted to the ICU intubated post-op as she had a metabolic academia with a pH of 7.12, and was requiring moderate-dose phenylephrine infusion to maintain her MAP at acceptable levels. She has known CAD and had a CABG x3 6 years ago.

During the course of her ICU admission she has required increasing phenylephrine and has had vasopressin added, and has been receiving repeated fluid boluses to maintain her MAP >60mmHg. Her CVP is 12mmHg; (she is being ventilated with 5cmH20 PEEP). A TEE is performed to further assess her hemodynamic state.

What is the hemodynamic state?

What is this most likely due to?

How would you proceed from here with treatment?